损伤性胆管狭窄外科处理的讨论

患者崔某，男，51岁，1991年8月14日在当地医院因胆囊结石择期行胆囊切除术，术后第3d开始出现皮肤、巩膜黄染，并进行性加重，对症处理后无效。于术后22d剖腹探查，发现胆总管损伤，放置T型管外引流。术后经T型管逆行性造影检查，发现胆总管下段阻塞。T型管不能夹闭，且出现间歇性畏寒、高热和黄疸等胆管炎症状。     

医源性胆道损伤的外科治疗

目的：探讨医源性胆道损伤的原因、诊断、手术时机和手术方式的选择。方法：对28例胆道损伤进行分析总结：分别施行了胆管修补术3例、胆管端端吻合术2例和胆肠吻合术23例。结果：全组无围手术期死亡，4例术后出现胆管狭窄而再次手术，其余愈后良好。结论：尽早发现、及早正确处理对提高疗效和预防术后胆管狭窄起着决定性的作用。术中发现胆管损伤立即行端端吻合或修复加T管引流；术后数天发现或多次重建术失败，则宜行规范的胆肠Roux-en-Y吻合术。     

医源性胆管损伤修复的时机及修复失败后的处理体会(附53例)

目的探讨医源性胆管损伤修复时间的选择和修复失败后的处理体会。方法回顾性分析和总结2004年1月～2011年12月我科收治的53例医源性胆管损伤及损伤修复后再狭窄的病例资料。结果 31例为首次修复,22例为修复后再狭窄病例,6例胆漏型病例行分期手术,21例梗阻型病例一期行胆管-空肠Roux-en-Y吻合,且损伤后10天内修复者手术时间长于十天后修复者,修复再狭窄病例分析,狭窄与首次修复时间选择无关,均再行胆管-空肠Roux-en-Y吻合,术后随访48例,2例术后一年出现吻合口狭窄。结论修复时间不是胆管损伤后修复失败的原因,对于单纯梗阻型胆管损伤,10天后进行修复手术难度下降,修复的最佳方式为胆管-空肠Roux-en-Y吻合术。     

胆管损伤的外科治疗

胆管是人体非常特殊的组织结构,它是一条纤细的管道,无可替代。一旦损伤,难以通过自身机制予以修复。目前也无类似于人工血管一样的材料替代。胆管损伤（bliliary duct injury,BDI）一直是困扰外科医师的一个棘手问题。在微创外科时代,胆管损伤一旦发生,会更严重和复杂,对患者也会造成更大的伤害。因此,胆管损伤的处理一直是外科领域的一个难点。     

十二指肠损伤的外科处理

探讨十二指肠损伤的诊治方法。方法　对 1993～ 1998年间手术治疗的十二指肠损伤患者的临床资料进行了回顾性分析。 5年间收治十二指肠损伤 37例 ,其中开放性损伤 2 9例 (78.4% ) ,闭合性损伤 8例(2 1.6 % ) ,合并伤 34例。行单纯缝合修补术 2 6例 ,十二指肠 空肠Roux en Y吻合术 2例 ,十二指肠憩室化 5例 ,胰十二指肠切除术 4例。结果　术后十二指肠瘘 3例 ,十二指肠狭窄 2例 ,肺部感染、胰漏等 9例 ,治愈 31例 ,死亡 6例。结论　十二指肠损伤术前诊断困难 ,术中易被漏诊 ,早期明确诊断 ,选择合理的术式是提高治愈率 ,降低并发症和死亡率的关键。     

医源性胆管损伤及损伤性胆管狭窄的现代外科处理

医源性胆管损伤和损伤性胆管狭窄是胆道外科永久的议题.大多数胆管损伤发生在对良性疾病的治疗,患者本可以获得满意的疗效.     

十二指肠损伤的外科处理

十二指肠损伤较为少见 ,我院近 5 0年收治的此类病例仅 4 7例。因十二指肠位置特殊 ,生理功能重要 ,诊断及处理十分困难 ,死亡率高。特别是中青年医师对诊断、处理本病的经验不足 ,容易造成误诊 ,处理不当 ,甚至引起患者的死亡。十二指肠损伤近年来有增多的趋势 ,其发病原因以车祸为最多 ,其次是工伤事故。患者多为青壮年 ,占 80 %以上 ,男性发病率高于 90 %。十二指肠损伤有 78.3%发生在腹部闭合性损伤 ;2 2 .7%发生在开放性损伤。以刀伤和锐器刺伤为主。损伤的部位以十二指肠降部最多 ,占 82 % ,其次为水平部、升部 ,球部极为少见。全部十…     

胆管结石与胆管医源性损伤致门静脉高压症的处理

目的 探讨胆管结石与胆管医源性损伤性狭窄所致门静脉高压症的外科处理.方法 回顾性分析我院十余年来收治的13例胆系结石、损伤引起门静脉高压症的外科处理的情况及预后.结果 一期手术4例,3例痊愈,1例死于肾功能衰竭;仅行胆系处理者9例,2例先后于术后51d、7年死于胆道大出血、肝功能衰竭.结论 对本病围手术期处理十分重要,关系到手术成败与否;在权衡肝功能的前提下,不失时机宜先解决胆道问题,可一期或分期手术,达到治愈本病.     

损伤性胆管狭窄外科治疗

自 1 8 82年ＣａｒｌＬａｎｇｅｎｂｕｃｈ首次施行胆囊切除术之后便一直存在胆管损伤的可能 ,但可能由于当时施行胆囊切除术的病例数少 ,直至 1 90 5年Ｍａｙｏ才首次报道 2例胆囊切除术后胆管狭窄并用胆总管十二指肠吻合术治疗[1 ] 。胆管损伤是一严重并发症 ,因而引起多方重视 ,并在临床上十分强调胆囊切除手术的正规化 ,使开放式胆囊切除术的胆管损伤率有明显降低。例如Ｒｏｓｌｙｎ( 1 993) [2 ] 复习 1 988- 1 989年 42 4 74例开放法胆囊切除术 (相当于该时美国的胆囊切除术总数的8% ) ,胆管损伤率已下降至 0 .2 %。在我国 ,胆囊切除…     

胆囊切除致肝外胆管损伤的外科处理

目的总结胆囊切除致肝外胆管损伤的处理经验。方法回顾我院11例肝外胆管损伤病人的外科处理，分析损伤的部位，类型，发现时间，手术方法及治疗效果。结果11例中3例为急诊手术，8例为择期手术；术中发现7例(62．7％)，术后发现4例(37．3％)。术中发现7例均立即进行了处理，术后发现4例于术后3～4d手术。全组病人均治愈出院。结论正确掌握胆囊切除致肝外胆管损伤的处理原则及方法。胆管空肠Roux-Y吻合术是处理胆管损伤的首选方法。     

Surgical injury of the common bile duct

Review of our experience with twenty-two bile duct injuries and the literature leads us to the following conclusions: (1) Most biliary strictures follow surgery and can be avoided by adequate exposure, accurate dissection, use of hemostatic clips rather than clamps and ties, and the liberal use of operative cholangiography. (2) Injuries diagnosed at the time of surgery should be repaired by end-to-end anastomosis over a T tube if length is adequate or by Roux-en-Y choledochojejunostomy if length is inadequate. (3) The diagnosis of biliary injury should be suspected when jaundice, biliary fistula, or cholangitis occur in the postoperative period. (4) IVC, PTC, ERCP, or fistulography should be used when possible to delineate the site of injury or stricture and assist in planning the operative repair. (5) Surgery should be performed as soon as the diagnosis is made and the patient is in satisfactory condition for operation. (6) Early reoperation may be necessary to establish drainage and prepare for a later definitive procedure. In some cases, definitive repair can be performed this time. (7) Most late strictures should be repaired with a choledochojejunostomy to a defunctionalized limb of jejunum when resection and primary end-to-end repair cannot be accomplished.     

胆管壁坏死的手术处理

目的 探讨胆管壁坏死外科手术处理.方法 回顾性分析了1990年5月至2008年12月收治的94例胆管壁坏死病人的临床资料.结果 无手术病死、无胆瘘、大出血等严重并发症.结论 根据胆管壁坏死的特点采用相应的手术方式.

Abstract：

Objective To explore the surgical treatment of bile duct necrosis.Methods Clinical data of 94 cases of bile duct necrosis treated in this hospital from May1990 to December 2008 were retrospectively analyzed.Results There were no death or severe complications such as biliary fistula and massive hemorrhage in these patients.Conclusion Bile duct necrosis should be treated with a proper surgical approach based on its features.     

创伤性肝胆管损伤的外科处理

目的探讨创伤性肝胆管损伤的处理方法。方法回顾性分析近10年我院收治220例肝创伤中12例肝胆管损伤患者的临床资料：结果除外院转入1例因来院过晚,失去手术时机衰竭死亡外,另11例均获痊愈：其中7例再手术治疗：1例持续胆漏予以近端漏口缝扎,胆总管引流;3例因反复发作化脓性胆管炎、梗阻性黄疸,行胆管空肠Roux—Y吻合术：另3例伴有肝萎缩、创伤性胆道出血分别行肝段、叶切除术。尚有4例胆漏维持通畅引流．亦获满意结果．于2周内停止胆漏。结论肝创伤合并肝胆管损伤,经初期和后期认真处理,均可获得良好预后．     

Surgical treatment of proximal bile duct tumors

A new classification of proximal bile duct tumors mainly based on endo- and exobiliary neoplastic invasion, indicating radical or palliative surgery is proposed. Fifty-eight patients underwent radical (12) or palliative (46) surgery. The 5-year survival rate of patients treated radically is 40% compared to 0% in patients treated palliatively; all the patients of this latter group died within 22 months. The authors stress the need for a standard anatomical classification for proximal bile duct tumors.     

Surgical treatment of hilar bile duct carcinoma

Carcinoma of the bile duct at the hepatic hilar region is not a rare condition but with a low resectability rate. The incidence of this disease seems to be on increasing. In a previous report, 60 cases were explored surgically from 1975 to 1985, but resection was only possible in 5 cases (9.1%); while in the recent years from June, 1986 to June 1989, 24 cases were explored in the Surgical Department of General Hospital of PLA, 16 cases were resected, with a resectability rate of 66%. The increase of resectability rate was due to earlier recognition of this condition and the extension of surgery, including major resection of liver as well as radical dissection of the hepato-duodenal ligament and reparative operations on the blood vessels. Among these 16 cases, major hepatic resection was performed in 10 cases, in which, 3 cases of resections of the middle lobe of the liver were done instead of right or extended right lobectomy. No operative mortality in the 30 days' postoperative period, but the postoperative morbidity rate was still high and most of the complications were related to biliary leakage and infect ion. Three patients died in the postoperative follow up period at 6.14 and 15 months respectively. All of them died from biliary infection. The remaining 13 patients were still living, the longest being 40 months and the average living time was 16.1 months. Probably, lowering of the operative mortality rate and morbidity rate are still the most important considerations in the surgical treatment of hilar carcinoma at the present time.(ABSTRACT TRUNCATED AT 250 WORDS)     

医源性胆管损伤内镜治疗

伴随腹腔镜胆囊切除术的普遍开展,医源性胆管损伤的发生率越来越高。微创时代胆管损伤及狭窄应采用综合治疗方案,即胆管损伤-胆道重建（留置通道）-胆道镜检查及治疗-及时发现问题必要时再次手术。